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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604501
Report Date: 07/07/2023
Date Signed: 07/07/2023 11:26:48 AM

Document Has Been Signed on 07/07/2023 11:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:DEL REY SPRINGSFACILITY NUMBER:
374604501
ADMINISTRATOR:GONZALEZ, EDUARDOFACILITY TYPE:
735
ADDRESS:1181 PLAZA AMPARADATELEPHONE:
(619) 990-8870
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 4CENSUS: 4DATE:
07/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:DSP Veronica Gomez-Zavala, Administrator Eduardo Gonzalez, and House Manager Melinda PontanaresTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Other visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with DSP Veronica Gomez-Zavala and House Manager Melinda Pontanares. LPA also spoke with Administrator Eduardo Gonzalez via phone during the visit.

Today's visit was in response to a 30-day written eviction notice, which Licensee served to Client #1 (C1) on 05/23/2023. [See LIC 811 Confidential Names List for a description of C1]. Licensee sent a copy of this eviction notice to the CCLD San Diego Regional Office (RO), and it was received on 05/23/2023.

During today’s visit, LPA performed a brief facility tour, reviewed pertinent care and administrative records, and interviewed relevant staff. As of the date of CCLD’s visit, C1 was no longer a resident of the facility. Per staff interviews, C1 moved out on 06/01/2023.

Per interviews and records reviewed: C1 did not comply the facility’s general policies / House Rules. The written eviction notice that licensee served stated this was the reason for C1’s eviction. However, the notice did not describe the “specific facts including the date, place, witnesses, and circumstances” underpinning that reason, as was required.

After reviewing the facility’s House Rules, which C1 signed upon move in, CCLD concluded that licensee had basis to issue a 30-day written eviction notice to C1. However, the written notice which licensee served, in practice, did not fully satisfy regulatory requirements. One (1) deficiency was cited per California Code of Regulations. A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Gomez-Zavala and Pontanares, to whom a copy of this report, the LIC-809D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2023 11:36 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/07/2023 11:33 AM


Created By: Dang Nguyen On 07/07/2023 at 10:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: DEL REY SPRINGS
FACILITY NUMBER: 374604501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2023
Section Cited
CCR
85068.5(c)

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85068.5 Eviction Procedures: “(c) The licensee shall set forth in the notice to quit the reasons for the eviction, with specific facts including the date, place, witnesses, and circumstances.” This requirement was not met, as evidenced by:
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Licensee agreed to amend its general template (which it relies on to draft written eviction letters) to include a field/reminder for staff to describe the specific date(s), place(s), witness(es), and circumstance(s) that are relied upon to justify the eviction. Licensee agreed to then submit a copy of its updated template to LPA by the POC due date.
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Based on record review: For 1 of 4 clients (C1), licensee did not set forth in the notice to quit the specific facts including the date, place, witnesses, and circumstances which support the stated reason for eviction, which posed a potential personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
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